Provider Demographics
NPI:1619236056
Name:MEADVILLE PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:MEADVILLE PHYSICIAN SERVICES
Other - Org Name:PRIMARY CARE SERVICES OF CRAWFORD COUNTY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RENATO
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNTAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-333-5031
Mailing Address - Street 1:1034 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2945
Mailing Address - Country:US
Mailing Address - Phone:814-373-3545
Mailing Address - Fax:814-333-5640
Practice Address - Street 1:765 LIBERTY ST STE 105
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2567
Practice Address - Country:US
Practice Address - Phone:814-373-2310
Practice Address - Fax:814-373-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADT1760OtherRR PTAN
PA0016541250027Medicaid
PA0016541250027Medicaid